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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENis <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: �,.p.� (r�,., �_ <br /> ct I r)vt�(� � l G Page of <br /> Facility Address: City: Inspection Date: <br /> FA#: LD <br /> PR#: <br /> Program Element: <br /> v 1(J ✓✓ <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. <br /> Complete one box for each tank or each cumulative container roduct tvpe. <br /> Al Tank (2820) ❑ Containers (2821) #of Containers: TA#: e951 TZeZ,9 <br /> 1 <br /> Total Capacity: S k Product Type: —LL gallons I, L 5 s.2.. "� <br /> (per tank or cumulative for containers by product type) Install Date: 1"-'uc,q,.i QVL . `r.��L1�K r <br /> k7 Tank (2820) ❑ Containers (2821) #of Containers: pp TA#: A,`i 19'Lo7'� <br /> 2 Total Capacity: .�-= gallons Product Type: OCA E <br /> (per tank orcumulative forcontainers by product type) Install Date: 6ry t'�L <br /> Tank (2820) ❑ Containers (2821) *of Containers: TA#: A, 12Z{ Z]z <br /> 3 Total Capacity: 2-G1) gallons Product Type: n.p, <br /> (per tank or cumulative for—contains ss by product type) Install Date: <br /> /] Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> 4 Total Capacity: Product Type: U SPI <br /> P Y� eS(��gallons <br /> (per tank or cumulative for containers by protluct type) Install Date: ' SIA' <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: �-7 � <br /> 5 Total Capacity: _ _ gallons Product Type: o <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: r( D gallons Total Capacity for Site: ��/ 7 gallons <br /> Comments: 1 <br /> to �2 <br /> EHD Inspector: Reviewed Date: Entered <br /> By Initial: Date: <br /> Ci"'�'tBy I <br /> O <br /> nitial: 7 <br /> *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum <br /> **Container means a storage device designed to be moved when full. <br /> EHD 28-01 <br /> 09/12/08 AST SURVEY FORM <br />